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US Health Issues

Sick Care vs Health Care:
The Crisis in US Health

Increasingly, the United States is challenging conventional wisdom that wealth = health. Current estimates put US health care spending at approximately 15% of gross domestic product (GDP), the highest in the world[1], but the health system fails to deliver efficient, effective, and equitable health services.  Overall, there is a systemic problem:  a huge gap between the care that everyone should receive, and what they actually receive – if they receive any at all.

On average, the United States has some of the world's best health indicators, including low infant mortality (7 per 1,000 live births); high life expectancy (78 years); and low maternal mortality (8 per 100,000 births). Additionally, in the two areas shown to have the greatest impact on disease prevention – vaccination rates and access to potable water – the US excels: between 90% and 95% of children under one year are immunized against major diseases and 100% of the urban population has access to improved drinking water; even in rural areas, 99% of the population enjoys such access.[2]

But peeling away at the national averages begins to expose health disparities and health care inequities based on race, age, socioeconomic position, geographic location, gender, and immigration status. Underlying the crisis in US health is the system itself, where 45 million people are uninsured (over 8 million of them children)[3], forcing large swaths of the population to rely on high cost, stop-gap emergency services that causes an estimated 18,000 deaths annually.[4]  When those emergency rooms and clinics shut down unexpectedly, as happened during Hurricane Katrina, the health of communities is plunged headlong into chaos, causing deepening illness, suffering, and in some cases, death.

Governmental policies aimed at increasing access to quality services are critical to improving the nation's health status equitably. And if public polls are any indication, such policies are urgently desired: in a March 2007 poll by the Kaiser Family Foundation, 29% of voters surveyed said health care is the most important problem in the country – second only to the war in Iraq (44%). In that same poll, 52% of respondents cited coverage for the uninsured as the top health reform priority.[5] Perhaps this is to be expected, considering that the USA is the only industrialized nation in the world without national health care.[6]
           
The Uninsured & Underserved

The scope of the US health crisis is both sweeping and complex.  As mentioned, the number of people without basic health care coverage ("the uninsured") is massive, with a large proportion of those being children and minorities. According to recently-released data from the Kaiser Foundation (see chart), the health of minority populations is in particular peril, more so when immigrant populations are factored in.  

Key Health Care Indicators by Race/Ethnicity: Selected States

*Other includes American Indian, Native Alaskan, Asian and Pacific Islander race groups.
--- Not sufficient data where the figure does not meet the standard of reliability.
Source: StateHealthFacts.org. Key Health & Health Care Indicators by Race/Ethnicity & State. Kaiser Family Foundation, April 2007. Available from: http://www.kff.org/minorityhealth/7633.cfm

As a group, children are one of the country's most vulnerable. This is tragedy times two, for when the system fails our children, it fails our future. It should not take a story like the April 2007 death of 12-year-old Deamonte Driver, who died of an abscessed tooth when the Medicaid safety net unraveled, to alert us to the fact that the system is need of profound repair. A first step to turning the tide on the US health crisis is raising our own awareness of health inequities and social determinants of health, as well as their effects on individuals and the society as a whole. 

The depth and breadth of the problem becomes even more alarming when the medically underserved are factored in. According to the US Department of Health and Human Services, underserved areas and populations are defined as those with "shortages of primary medical care, dental, or mental health providers, and may be geographic or demographic."[7] The latter category is divided by low income, Medicaid-eligible, cultural and/or linguistic. In 2006, there were 30 million people living in federally-designated underserved areas[8], essentially putting them beyond practical access to the most basic medical and dental services. 
 
Disparities in health care aggravate disparities in health status. While behavioral factors including smoking, drinking, diet, stress, and exercise all play into health, structural determinants (eg, race, ethnicity, gender, socioeconomic status, housing conditions, access to educational opportunities, etc) play an equally important role. Indeed, some argue these factors have a stronger causal relationship to health and well-being because, to an extent, they predetermine behavioral factors. For example, a family that lives in an unsafe neighborhood without sidewalks or a playground is less likely to be physically active. Taken together, this means that poor and minority communities in the USA are more likely than whites to die of a host of chronic and communicable diseases, from obesity to AIDS.

Death Rates by Race & Ethnicity, 2001 (per 100,000)

Source: Centers for Disease Control & Prevention

Is There a Doctor in the House? Increasingly Unlikely

It’s now widely recognized that training more doctors, nurses, specialists, and technicians, coupled with policies to promote more equitable distribution of these health professionals, must figure into any strategy for comprehensive reform. The United States has a physician-patient ratio of 264:100,000, which places it 13th out of 20 OECD countries in this indicator, after countries such as Italy, Portugal and the Slovak Republic.[9] Furthermore, the Association of American Medical Colleges (AAMC) predicts there will be an acute shortage of physicians in the US by 2020.[10] The nursing shortage is equally grave, with estimates projecting a shortage of 800,000 nurses by the same year.[11]

The good news is that medical school enrollment is on the rise, increasing by over 2% from 2005 to 2006; applications to medical school were up by almost 5% for the same period.[12] It remains to be seen whether these increases will be enough to offset the 250,000 physicians (1 of 3 currently practicing) slated to retire in the next 20 years[13], coupled with the graying of the baby boomer generation (certain to place increasing demands on the health system). Nevertheless, it's a step in the right direction, as are the increasingly diverse application and enrollment figures, although the proportion of minority physicians is still well below these groups' representation in society as a whole. According to the Sullivan Commission on Diversity in the Health Care Workforce, African Americans, Hispanics, and Native Americans together make up more than 25% of the population, but comprise less than 9% of nurses, 6% of physicians, and 5% of dentists.[14]

While efforts by US medical schools to scale up the physician workforce are under way, problems remain, including:

• barriers to access for minority and low-income students;
• under-representation of minorities in the health professions generally and chronic under-representation in the upper strata of university hierarchies;
• over reliance on international medical graduates (IMGs), which contributes to brain drain in developing countries;
• inequitable distribution of doctors, leaving rural, minority, and poor communities underserved; and
• imbalance in choice of specialization, particularly in primary care.

Putting the Public Back in Public Health

The US model is a mix of private and public health care that has been creeping towards the former at the expense of the latter. This strategy of moving away from public health coverage is reinforced in the 2008 federal budget proposal:  Medicaid and Medicare, the federal programs providing basic medical services to the poor and elderly respectively, would be cut by a combined $92 billion; rural health programs by $143 million.[15] And while the budget calls for reauthorizing the State Children Health Insurance Program (SCHIP), it does so at lower funding targets, meaning large numbers of children currently covered under the program – many from underserved communities – will lose their basic medical insurance.

Proposed 2008 budget slashes also target federal prevention programs, such as the Preventive Health and Health Services Block Grant. This grant, which previously funded important state health initiatives including cancer screenings and physical activity programs for youth, would be dispensed with entirely. 
 
That such policies have the distinct potential to adversely affect poor, elderly, and rural populations – in other words, the already underserved – is just one of the criticisms being leveled against them. The other is more fundamental: that tax deductions and shifting of responsibility to states (via the Affordable Choices Initiative) do not address what is basically wrong with a system that leaves 15% of its population without health coverage, forcing them to rely on emergency services, neglect the onset of chronic disease (an increasingly critical problem disproportionately affecting the nation's poor), and forsake health prevention for health crisis management.
 
Turning the Tide

Although US population health is suffering from its own form of chronic disease, the diagnosis is not terminal.  Most importantly, evidence-based experience and knowledge exist as a foundation for building a better, more effective and equitable health system.  Taken together, recent studies point to the need to generate:

• a bigger and better distributed health workforce, trained in specialties to prevent, as well as treat, disease ('getting the right people with the right skills to the right places');
• a more diverse health workforce;
• more accessible and affordable medical education;
• closer integration of services and agencies working in fields of health and well being;
• realistic, but at the same time, more aggressive and effective resource allocation to tighten the public health safety net; and
• a pro-active citizenry that demands health care from its public officials and institutions and takes steps to improve and protect its own health.

Finally, the World Health Organization and many US health policy centers have long urged a philosophical shift away from crisis health management/disease control and towards health promotion/disease prevention. But that's a tall order, and until there is a system in place aimed at extending health care equitably to all the country’s citizens, it’s doubtful such a shift will take hold.  The political will for change is the real question mark for health and health care in the USA; will health care be just another business, and the public’s health just business as usual?  Or will all Americans be able to count on health care for themselves, their families, and communities?

References

1. World Health Organization. World Health Report, 2006. Geneva: World Health Organization; 2006.
2. All data this section from: Human Development Index, 2006. United Nations Development Programme, 2006.
3. Ku L. Census Revises Estimates of the Number of Uninsured People. Center on Budget and Policy Priorities; Washington DC: April 5, 2007.
4. According to the Institute of Medicine, some 18,000 people die per year unnecessarily due to lack of health insurance. Source: Institute of Medicine. Insuring America's Health: Principles and Recommendations. Washington, DC: Institute of Medicine;2004.
5. Kaiser Family Foundation. Kaiser Health Tracking Poll: Election 2008; March 2007. 
6. Davis K. Uninsured in America: Problems and Possible Solutions, 2007. Commonwealth Fund; 2007.
7. Health Resources & Services Administration.gov [homepage on the Internet]. Washington, DC: US Department of Health & Human Services. Medically Underserved Areas/Medically Underserved Populations. Available from: www.muafind.hrsa.gov/
8. Association of American Medical Colleges. Help Wanted: More US Doctors. AAMC; 2006.
9. idid.
10. ibid.
11. Dower, C et al. Diversifying the Nursing Workforce: A California Imperative. California Workforce Initiative; Feb 2001.
12. Association of American Medical Colleges. Medical School Enrollment Rises. AAMC; November, 2006.
13. Association of American Medical Colleges. Help Wanted: More US Doctors. AAMC; 2006.
14. DiversityAlliedHealth.com [homepage on the Internet]. Sullivan Commission on Diversity in the Health Care Workforce; c 2003-2007 [cited 3 May 2007]. Available from http://www.diversityalliedhealth.com/features/08-04-04d.htm
15. American Public Health Association.  Reductions in Health Protection and Disease Prevention Programs Undercut Savings in Federal Budget, Says APHA. Washington DC: APHA; February 5, 2007.

©MEDICC, 2007